The history and physical examination and their place in the world of error-free medicine….

For years, older doctors have lamented the loss of history and physical examination skills by current doctors. They will point to the large number of labs and tests that are now ordered that could have all been avoided with a good history and physical examination. I say, be careful with that sort of attitude.
History and physical examination provide qualitative data, not quantitative data. That means that the person doing the exam has a great effect on the findings. If you had ten physicians take a history and examine someone with abdominal pain, you would likely get three different diagnoses and plans. Now that’s pretty good actually, at least you are not getting 10 different diagnoses and plans, so I will say the H&P has some discriminatory value. But if you were to draw 10 blood samples from the same patient over an hour, its very unlikely you would see any significant variation, and if you did, it would be a results of something wrong with the analyzer, not the person drawing the labs.
The H&P are wonderful for finding out about a patients medical and surgical history, allergies, medications, and general physical condition, but it has definite limits. Despite all the time spent in medical school on listening and identifying murmurs, no cardiologist in the US would make a definitive valve diagnosis based on what they heard with their stethoscope. They would obtain further confirmatory tests. And certainly no cardiac surgeon would replace a valve based on a physical exam. The purpose of the exam in most patients is to function as a screen. I think most of us can elicit pain fairly well, can identify abnormal skin lesions, identify gross nerve deficits, etc. But would I ever open someone’s abdomen based on a physical exam? Only in two cases, where a wound has traversed the abdominal wall and omentum or bowel is hanging out, or a gunshot wound that has clearly traversed the abdomen. Otherwise we usually get either a FAST or CT. When patients are hypotensive, we have a lower threshold for going to the OR based on the exam, but we still like to see fluid in the abdomen on ultrasound or CT.
Why is this so? Because in previous decades, we accepted a certain error rate as part of medical care. You knew that you couldn’t get tests on everyone so you used the H&P to stratify risk. If the risk was very low on exam, you knew it was likely the patient did not have something life threatening going on, and would return if things got worse (hopefully). In this day and age, missing a major diagnosis and hoping the patient comes back before they suffer irreparable harm is just too risky. We set the bar much lower for getting quantitative (laboratory) and semi-quantitative (radiology) data to make certain nothing is going on. If you have the philosophy that “you need to prove the patient is OK, its not the patient’s job to prove to you they are sick” then you will need to obtain tests to “rule out” conditions frequently. Also, because life threatening problems are rare among your average 1,000 ED patients, your tests are often going to be negative and you will be scolded for wasting money.
We need to get a better handle on what is wasteful testing and what is appropriate. Most of the studies in this area are not good, mostly due to the difficulty in studying this problem. It is also very important to know that physical exam and history taking skills are very user dependent and experience dependent. So a person with 1-2 years of medical experience will not be able to differentiate issues that someone with 10 years experience possibly could.
So be careful, if you think the patient doesn’t look right, or there is disagreement about the physical exam and history findings, get more data.
JY

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